Apparatus for spinal fixation and methods of use

ABSTRACT

In some embodiments, a method comprises forming a lumen in a first bone portion and forming a lumen in a second bone portion. The method further includes inserting a portion of a flexible fastening band through the lumen in the first bone portion and through the lumen in the second bone portion, and inserting the portion of the flexible fastening band into a fastener mechanism monolithically formed with the flexible fastening band. The method further includes advancing the portion of the flexible fastening band through the fastener mechanism until the first bone portion and the second bone portion are stabilized.

CROSS-REFERENCE AND RELATED APPLICATIONS

This application is a continuation application of U.S. patentapplication Ser. No. 15/784,577, filed Oct. 16, 2017, which is adivisional application of U.S. patent application Ser. No. 13/804,407,filed Mar. 14, 2013. This application is related to U.S. patentapplication Ser. No. 29/448,946 entitled “Flexible Elongate Member witha Portion to Receive a Bone Anchor,” filed on Mar. 14, 2013.

BACKGROUND Background

Some embodiments described herein relate generally to methods andapparatus for stabilizing bone, for example, stabilizing vertebrae bysecuring the articular processes of the vertebrae.

Traumatic, inflammatory, and degenerative disorders of the spine canlead to severe pain and loss of mobility. One source of back and spinepain is related to degeneration of the facets of the spine or facetarthritis. Bony contact or grinding of degenerated facet joint surfacescan play a role in some pain syndromes. While many technologicaladvances have focused on the intervertebral disc and artificialreplacement or repair of the intervertebral disc, relatively littleadvancement in facet repair has been made. Facet joint and discdegeneration frequently occur together.

The current standard of care to address the degenerative problems withthe facet joints is to fuse the two adjacent vertebrae. By performingthis surgical procedure, the relative motion between the two adjacentvertebrae is stopped, thus stopping motion of the facets and anypotential pain generated as a result thereof. Procedures to fuse twoadjacent vertebrae often involve fixation and/or stabilization of thetwo adjacent vertebrae until the two adjacent vertebrae fuse.

Injuries and/or surgical procedure on and/or effecting other bones canalso result in the desire to fixate and/or stabilize a bone until thebone, or bone portions, can fuse, for example, to stabilize a sternumafter heart surgery, to stabilize a rib after a break, etc. Currentprocedures to fixate and/or stabilize adjacent vertebrae and/or otherbones, however, can be slow and/or complex.

Accordingly, a need exists for an apparatus and methods to betterstabilize and/or fixate a bone.

SUMMARY

In some embodiments, a method comprises forming a lumen in a first boneportion and forming a lumen in a second bone portion. The method furtherincludes inserting a portion of a flexible fastening band through thelumen in the first bone portion and through the lumen in the second boneportion, and inserting the portion of the flexible fastening band into afastener mechanism monolithically formed with the flexible fasteningband. The method further includes advancing the portion of the flexiblefastening band through the fastener mechanism until the first boneportion and the second bone portion are stabilized.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a lateral elevational view of a portion of the vertebralcolumn.

FIG. 2A is an example of a superior view of an isolated thoracicvertebra.

FIG. 2B is an example of a side view of an isolated thoracic vertebra.

FIG. 3A is an example of a posterior elevational view of a portion ofthe vertebral column.

FIG. 3B is an example of a posterior-oblique elevational view of aportion of the vertebral column.

FIG. 4A is an example of a side view of a facet joint in the cervicalvertebrae.

FIG. 4B is an example of a superior view of a facet joint in thecervical vertebrae.

FIG. 5A is an example of a side view of a facet joint in the thoracicvertebrae.

FIG. 5B is an example of a superior view of a facet joint in thethoracic vertebrae.

FIG. 6A is an example of a side view of a facet joint in the lumbarvertebrae.

FIG. 6B is an example of a superior view of a facet joint in the lumbarvertebrae.

FIG. 7 is a block diagram of a flexible elongate body according to anembodiment.

FIGS. 8A and 8B are schematic illustrations of a flexible elongate bodyaccording to an embodiment.

FIG. 9A is a posterior perspective view of a portion of the vertebralcolumn depicting a stabilized vertebra including a flexible elongatebody, a spacer, and an anchor, according to an embodiment.

FIG. 9B is an enlarged view of a portion of the vertebral column of FIG.9A identified as region X₁.

FIG. 10A is a posterior view of the portion of the vertebral column ofFIG. 9A depicting the stabilized vertebra including the flexibleelongate body, the spacer, and the anchor.

FIG. 10B is an enlarged view of a portion of the vertebral column ofFIG. 10A identified as region X₂.

FIGS. 11A-11C are various views of a flexible elongate body according toanother embodiment.

FIG. 12A is a posterior perspective view of a portion of the vertebralcolumn depicting a stabilized vertebra including the flexible elongatebody illustrated in FIGS. 11A-11C and a spacer.

FIG. 12B is an enlarged view of a portion of the vertebral column ofFIG. 12A identified as region X₃.

FIGS. 13A-13C are various views of a flexible elongate body according toyet another embodiment.

FIG. 14A is a posterior perspective view of a portion of the vertebralcolumn depicting a stabilized vertebra including the flexible elongatebody illustrated in FIGS. 12A-12C.

FIG. 14B is an enlarged view of a portion of the vertebral column ofFIG. 14A identified as region X₄.

FIG. 15 is a posterior perspective view of a portion of the vertebralcolumn depicting a stabilized vertebra including a flexible elongatebody and a spacer, according to an embodiment.

FIG. 16 is a flowchart illustrating a method of stabilizing a boneportion according to an embodiment.

DETAILED DESCRIPTION

In some embodiments, a method comprises forming a lumen in a first boneportion and forming a lumen in a second bone portion. The method furtherincludes inserting a portion of a flexible fastening band through thelumen in the first bone portion and through the lumen in the second boneportion, and inserting the portion of the flexible fastening band into afastener mechanism monolithically formed with the flexible fasteningband. The method further includes advancing the portion of the flexiblefastening band through the fastener mechanism until the first boneportion and the second bone portion are stabilized.

In some embodiments, an apparatus includes a flexible elongate body andan anchor. The flexible elongate body includes a distal end portion, abody portion, and an attachment connection. The attachment connectionreceives the distal end portion of the flexible elongate body when thebody portion is disposed in contact with a first bone portion and asecond bone portion. The anchor receives a fastener configured to securethe flexible elongate body to the first bone portion via the anchor.

In some embodiments, a kit includes a flexible band and a fastener. Theflexible band includes an interface portion configured to receive thefastener. The flexible band is configured to stabilize a first boneportion and a second bone portion. The fastener is configured to anchorthe flexible band to the first bone portion such that the first boneportion, the second bone portion, and the flexible band are stabilizedafter being anchored.

As used in this specification, the singular forms “a,” “an” and “the”include plural referents unless the context clearly dictates otherwise.Thus, for example, the term “a ratchet” is intended to mean a singleratchet or a combination of ratchets. As used in this specification, asubstance can include any biologic and/or chemical substance, including,but not limited to, medicine, adhesives, etc. While exemplary referencesare made with respect to vertebra, in some embodiments another bone canbe involved. While specific reference may be made to a specificvertebra, a subset of vertebrae, and/or a grouping of vertebrae, it isunderstood that any vertebra, subset, and/or grouping, or combination ofvertebrae can be used.

The words “proximal” and “distal” generally refer to the directioncloser to and away from, respectively, a center of a body. Theembodiments described herein, however, can be arranged in anyorientation relative to the center of the body. Thus, when discussingthe embodiments described herein (specifically a flexible elongatebody), the terms “proximal” and “distal” refer to a direction closer toand away from, respectively, an attachment connection or fastenermechanism, the position of which is visually presented with respect tospecific embodiments in the attached figures.

As shown in FIG. 1, the vertebral column 2 includes a series ofalternating vertebrae 4 and fibrous discs 6 that provide axial supportand movement to the upper portions of the body. The vertebral column 2typically comprises thirty-three vertebrae 4, with seven cervical(C1-C7), twelve thoracic (T1-T12), five lumbar (L1-15), five fusedsacral (S1-S5) and four fused coccygeal vertebrae. FIGS. 2A and 2Bdepict a typical thoracic vertebra. Each vertebra includes an anteriorbody 8 with a posterior arch 10. The posterior arch 10 includes twopedicles 12 and two laminae 14. The two laminae 14 join posteriorly toform a spinous process 16. Projecting from each side of the posteriorarch 10 is a transverse process 18, a superior process 20, and aninferior articular process 22. The facets 24, 26 of the superiorprocesses 20 and the inferior articular processes 22 form facet joints28 with the articular processes of the adjacent vertebrae (see FIGS. 3Aand 3B). The facet joints are synovial joints with cartilaginoussurfaces and a joint capsule.

The orientation of the facet joints vary, depending on the level of thevertebral column. In the C1 and C2 vertebrae, for example the facetjoints are parallel to the transverse plane. FIGS. 4A to 6B depictexamples of the orientations of the facet joints at different levels ofthe vertebral column. In the C3 to C7 vertebrae examples shown in FIGS.4A and 4B, the facets are oriented at a 45-degree angle to thetransverse plane 30 and parallel to the frontal plane 32, respectively.This orientation allows the facet joints of the cervical vertebrae toflex, extend, lateral flex and rotate. At a 45-degree angle in thetransverse plane 30, the facet joints of the cervical spine can guide,but do not limit, the movement of the cervical vertebrae. FIGS. 5A and5B depict examples of the thoracic vertebrae, where the facets areoriented at a 60-degree angle to the transverse plane 30 and a 20-degreeangle to the frontal plane 32, respectively. This orientation is capableof providing lateral flexion and rotation, but only limited flexion andextension. FIGS. 6A and 6B illustrate examples of the lumbar region,where the facet joints are oriented at 90-degree angles to thetransverse plane 30 and a 45-degree angle to the frontal plane 32,respectively. The lumbar vertebrae are capable of flexion, extension andlateral flexion, but little, if any, rotation because of the 90-degreeorientation of the facet joints in the transverse plane. The actualrange of motion along the vertebral column can vary considerably witheach individual vertebra.

In addition to guiding movement of the vertebrae, the facet joints alsocontribute to the load-bearing ability of the vertebral column one studyby King et al. Mechanism of Spinal Injury Due to CaudocephaladAcceleration, Orthop. Clin. North Am., 6:19 1975, found facet jointload-bearing as high as 30% in some positions of the vertebral column.The facet joints may also play a role in resisting shear stressesbetween the vertebrae. Over time, these forces acting on the facetjoints can cause degeneration and arthritis.

In some embodiments described herein, a flexible elongate body can beanchored to a first vertebra via an anchor and can be used to stabilizeand/or fixate a first vertebra to a second vertebra to reduce the pain,to reduce further degradation of a spine (e.g., a specific vertebraand/or a specific disc of a spine), and/or until the first vertebra andthe second vertebra have fused. FIG. 7 is a schematic block diagram of aflexible elongate body 140 (also referred to herein as “flexible band”or simply “band”) and an anchor 180, according to an embodiment. Theband 140 includes at least a body portion 145, a distal end portion 148,and an attachment connection 150 (alternatively referred to herein as“fastener mechanism”). The band 140 can be formed from any suitablebiocompatible material such as, for example, stainless steel, titanium,polyether ether ketone (PEEK), nylon, or the like. Moreover, the band140 can be any suitable shape, size, or configuration. In someembodiments, the size or shape of the band 140 can be associated with anintended usage. For example, in some embodiments, a first band can beintended to stabilize and/or fixate one or more cervical vertebra and asecond band can be intended to stabilize and/or fixate one or morelumbar vertebra. In this manner, the first band can have a first sizethat is substantially smaller than a second size of the second band. Inother embodiments, the size and shape need not be associated with anintended usage.

The fastener mechanism 150 is configured to accept at least a portion ofdistal end portion 148 and/or the body portion 145, as further describedherein. The fastener mechanism 150 is disposed at a proximal end of theband 140. In some embodiments, the fastener mechanism 150 defines alumen (not shown in FIG. 7) configured to accept at least a portion ofdistal end portion 148 and/or the body portion 145. In some embodiments,the lumen of fastener mechanism 150 can have a cross-sectional area thatis significantly smaller than a cross-sectional area of at least aportion of the body portion 145. In this manner, the portion of the bodyportion 145 can be prevented from advancing through fastener mechanism150. In some embodiments, the fastener mechanism 150 can include aratchet (not shown in FIG. 7) configured to engage a surface of thedistal end portion 148 and/or the body portion 145. In this manner, thefastener mechanism 150 can be configured to allow the distal end portion148 and/or the body portion 145 to advance through fastener mechanism150 in a first direction and substantially limit the movement of thedistal end portion 148 and/or the body portion 145 in a seconddirection, opposite the first direction.

The body portion 145 is a linear elongate that extends from a portion ofthe fastener mechanism 150. More specifically, the body portion 145 ofthe band 140 can be monolithically formed with the fastener mechanism150 such that the body portion 145 is a linear elongate portion betweenthe fastener mechanism 150 and the distal end portion 148. In otherembodiments, the body portion 145 can be coupled to the fastenermechanism 150 in any suitable manner (e.g., coupled via an adhesive, aweld, a friction fit, a threaded fit, or the like). The body portion 145can be any suitable configuration. For example, in some embodiments, thebody portion 145 can have a cross-sectional shape that is polygonal(e.g., square, rectangular, trapezoidal, etc.) or oval (e.g., circular,elliptical, oblong, etc.). In some embodiments, the cross-sectionalshape of the body portion 145 can be associated with one or morecharacteristics of the bone or bone portion against which the bodyportion 145 may contact. For example, while the body portion 145 canhave a substantially square cross-sectional shape, a set of edges of thebody portion 145 can be rounded, partially rounded, and/or otherwiseshaped to compliment the shape of a bone or bone portion, and/or toreduce digging or grinding into the bone or bone portion. In thismanner, use of band 140 may cause little or no damage to the bone orbone portions contacted by band 140.

In some embodiments, the body portion 145 can define a substantiallyuniform cross-sectional area along a longitudinal axis (e.g., acenterline) of the band 140. In other embodiments, the cross-sectionalarea of the body portion 145 can vary along the longitudinal axis(centerline) of the band 140. For example, in some embodiments, the bodyportion 145 can have a cross-sectional area that is substantiallytapered (i.e., reduced) from a proximal end (e.g., adjacent the fastenermechanism 150) to a distal end (e.g., adjacent the distal end portion148). In some embodiments, the cross-sectional area of the body portion145 can be associated with the cross-sectional area of the lumen definedby the fastener mechanism 150 (the attachment connection 150 describedabove). In this manner, at least a portion of the body portion 145 canhave a cross-sectional area that is sufficiently small such that thebody portion 145 can be at least partially disposed within the lumen ofthe fastener mechanism 150.

The body portion 145 can be configured to include a gear rack (not shownin FIG. 7) configured to engage the ratchet (not shown in FIG. 7) of thefastener mechanism 150. As described above, the gear rack can beconfigured to engage the ratchet of the fastening member 150 such thatthe ratchet allows the body portion 145 to travel through the fastenermechanism 150 in the first direction and substantially limits themovement of the body portion in the second direction, opposite the firstdirection. In some embodiments, the gear rack can be configured toinclude a set of individual gears that extend from a surface of the bodyportion 145. In other embodiments, the body portion 145 can define theset of individual gears (e.g., the gears each include a top surface thatis disposed at or below a surface of the body portion 145). The gearsincluded in the set of gears can be any suitable shape, size, orconfiguration. For example, in some embodiments, the gears aresubstantially cubed. In other embodiments, the gears can be triangularsuch that the gears form, for example, teeth. In this manner, the gearsincluded in the gear rack can be configured to engage the ratchet of thefastener mechanism 150, as described above.

The distal end portion 148 is configured to extend from the body portion145 of the band 140. More specifically, the distal end portion 148 isdisposed adjacent the distal end of the body portion 145 such that thebody portion 145 is disposed between the distal end portion 148 and thefastener portion 150. In some embodiments, the distal end portion 148can have a cross-sectional area that is substantially similar to thecross-sectional area of the body portion 145. In other embodiments, thedistal end portion 148 can have a cross-sectional area that issubstantially smaller than the cross-sectional area of the body portion145. In such embodiments, the distal end portion 148 and the bodyportion 145 can collectively define a discontinuity defining a stepwisereduction in the cross-sectional area. In other embodiments, the bodyportion 145 and/or the distal end portion 148 can define a taperedportion such that the band 140 is tapered between smallercross-sectional area of the distal end portion 148 and the largercross-sectional area of the body portion 145.

While not shown in FIG. 7, in some embodiments, the distal end portion148 can include a gear rack that is substantially similar to the gearrack of the body portion 145. In this manner, the gear rack can extendsubstantially continuously across a portion of the distal end portion148 and a portion of the body portion 145. In other embodiments, thedistal end portion 148 of the band 140 need not include or define a gearrack.

The anchor 180 is configured to receive a fastener 185 to secure theband 140 to a bone portion. In some embodiments, the anchor 180 ismonolithically formed with the band 140. For example, in someembodiments, the anchor 180 can be disposed on or within the bodyportion 145 and can define an aperture (not shown in FIG. 7) configuredto receive the fastener 185 (e.g., a mechanical fastener such as ascrew, bolt, staple, nail, etc.). In other embodiments, the anchor 180is a protrusion extending from the body portion 145 in a substantiallyperpendicular direction (e.g., relative to the longitudinal axis of theband 140). In other embodiments, the anchor 180 can be a protrusion thatextends in an angular direction from the body portion 145 or the distalend portion 148 (e.g., non-perpendicular to the body portion 145 or thedistal end portion 148). In some embodiments, the anchor 180 can be aportion of the band 140 including a surface configured to receive thefastener 185. For example, in such embodiments, the anchor 180 can havea surface configured to receive a biocompatible adhesive or tape.

In some embodiments, the anchor 180 can be formed independently from theband 140 and can be at least partially disposed about the band 140 tosecure the band 140 to the bone portion. For example, in someembodiments, the anchor 180 can define a second aperture configured toreceive the distal end portion 148 of the band 140. In this manner, theanchor 180 can define a strap or loop configured to be slid into anysuitable position along the distal end portion 148 and/or the bodyportion 145. In some embodiments, the anchor 180 can form a hook (e.g.,a J-hook, an L-hook, etc.). In this manner, the anchor 180 can beconfigured to engage at least three sides of the band 140. In suchembodiments, the anchor 180 can include an edge configured to engage asurface of the bone portion to retain the band 140 between the edge andthe fastener 185 when the fastener 185 is disposed within the secondaperture (e.g., defined by the anchor 180) and the bone portion, asdescribed in further detail herein.

In use, the band 140 can be configured, for example, to stabilize avertebra (e.g., a first vertebra) and/or a second vertebra by securingan articular process of the first vertebra to an articular process of asecond vertebra. More specifically, the band 140 can be configured tostabilize the first vertebra and/or a second vertebra by securing anarticular process of the first vertebra to an articular process of asecond vertebra by securing a facet of the articular process of thefirst vertebra with a facet of the articular process of the secondvertebra. For example, the band 140 can be placed into a suitableposition relative to the first vertebra and/or the second vertebra, andthe distal end portion 148 of the band can be inserted into the lumen ofthe fastener member 150 such that the body portion 145 substantiallyencircles at least a portion of the first vertebra and the secondvertebra. Similarly stated, the distal end portion 148 can be insertedin to the lumen of the fastener mechanism 150 such that the band 140forms a loop about the articular process of the first vertebra and thearticular process of the second vertebra. In this manner, the distal endportion 148 and/or the body portion 145 can be advanced through thelumen of the fastener mechanism 150 such that the volume disposed withinthe loop formed by the band 140 is reduced. Thus, the band 140 exerts acompressive force on the articular process of the first vertebra and thearticular process of the second process. While not shown in FIG. 7, insome embodiments, a spacer can be disposed between the articular processof the first vertebra and the articular process of the second processsuch that a desired distance between the articular process of the firstvertebra and the articular process of the second process is maintained.In some embodiments, the spacer can include and/or define a portionconfigured to reduce slippage of the band 140 along a surface of thefirst vertebra and/or the second vertebra. Examples of spacers arefurther defined below with respect to specific embodiments.

With the band 140 at least partially tightened about the articularprocess of the first vertebra and the articular process of the secondvertebra, the fastener 185 can be inserted into the anchor 180 andadvanced into a portion of the articular process of the first vertebraand/or second vertebra. In some embodiments, the fastener 185 can beadvanced through a pre-drilled hole of the articular process. In otherembodiments, the fastener 185 can be configured to self-tap into thearticular process (e.g., when the fastener is a self taping screw). Inthis manner, the anchor 180 can be affixed to the articular process ofthe first vertebra and/or the second vertebra such that the anchor 180secures the band 140 to the first vertebra and/or the second vertebra.In this manner, the distal end portion 148 and/or the body portion 145can be advanced through the lumen defined by the fastener mechanism 150to stabilize and/or fixate the first vertebra to the second vertebra.Furthermore, by affixing the anchor 180 to the first vertebra and/or thesecond vertebra, the anchor 180 can substantially reduce slippage of theband 140 relative to the first vertebra and/or the second vertebra.

While not explicitly described above, in embodiments wherein the anchor180 is independently formed, the anchor 180 can be disposed about thedistal end portion 148 and/or the body portion 145 prior to insertingthe distal end portion 148 into the lumen of the fastener member 150.While being described above as being partially tightened about the firstvertebra and the second vertebra prior to affixing the anchor 180, inother embodiments, the anchor can be affixed to the first vertebraand/or the second vertebra prior to inserting the distal end portion 148into the fastener mechanism 150. Conversely, in some embodiments, theband 140 can be tightened to a desired amount prior to the anchor 180being affixed to the first vertebra and/or the second vertebra.

FIG. 8A is a side view and FIG. 8B is a top view of a flexible elongatebody 240 (also referred to herein as “band”) according to an embodiment.The band 240 can be similar to the band 140 described above and caninclude similar components. For example, the band 240 includes anattachment connection 250 (also referred to herein as “fastenermechanism”) including a ratchet 262, a body portion 245 including a gearrack 247, and a distal end portion 248. Accordingly, components of theband 240 that are similar to corresponding components of the band 140described above with reference to FIG. 7 are not described in furtherdetail herein.

As shown in FIG. 8A, each gear 264 included in the gear rack 247includes a cross sectional area that is rectangular in shape. Saidanother way, each gear 264 can be a rectangular protrusion configured toextend from a surface of the band 240 (e.g., the body portion and/or thedistal end portion 248). The gear rack 247 is configured to engage theratchet 262 of the fastener mechanism 250, as further described herein.The fastener mechanism 250 defines a lumen 266. The lumen 266 can be anysuitable shape, size, or configuration. For example, as shown in FIG. 8Bthe lumen 266 can have a substantially circular cross-sectional area.The ratchet 262 extends from an inner surface of the fastener member 250such that the ratchet 262 substantially reduces the size (e.g., theperimeter, circumference, and/or cross-sectional area) of the lumen 266.In this manner, the ratchet 266 can engage the gear rack 247. Morespecifically, as described in detail with reference to FIG. 7, thedistal end portion 248 can be inserted into the lumen 266 of thefastener mechanism 250 and advanced in a first direction such that thegear rack 247 of the distal end portion 248 engages the ratchet 262. Insome embodiments, the distal end portion 248 can be advanced through thelumen 266 a sufficient distance such that a portion of the body portion245 is disposed within the lumen 266. In such embodiments, a portion ofthe gear rack 247 disposed on (e.g., included in or defined by) the bodyportion 245 can engage the ratchet 262. In this manner, the arrangementof the ratchet 262 and the gear rack 247 can be such that the distal endportion 248 can be moved in the first direction, thereby tightening theband 240, and the distal end portion 248 can be prevented from moving ina second direction, opposite the first direction, thereby preventing theband 240 from loosening.

The band 240 can be used in any suitable procedure to stabilize and/orfixate a first bone portion to a second bone portion. For example, insome embodiments, the band 240 can be disposed about an articularprocess of a first vertebra and an articular process of a secondvertebra. In this manner, the distal end portion 248 and/or the bodyportion 245 can be positioned within the lumen 266 of the fastenermechanism 250 such that the band 240 forms a loop of suitable tightnessabout the first vertebra and the second vertebra. The band 240 can beused in conjunction with any suitable anchor configured to facilitatethe stabilization and/or fixation of the first vertebra to the secondvertebra and further configured to reduce potential slippage of the band240 relative to the first vertebra and/or the second vertebra (asdescribed in detail above with reference to FIG. 7).

In some embodiments, the band 240 can be used in any procedure describedin or similar to those in U.S. patent application Ser. No. 12/859,009;filed Aug. 18, 2010, and titled “Vertebral Facet Joint Drill and Methodof Use” (referred to as “the '009 application”), the disclosure of whichis incorporated herein by reference in its entirety. In someembodiments, the band 240 can be used in conjunction with a spacer suchas those described in the '009 application. For example, the spacer canbe implanted and deployed to restore the space between facets of asuperior articular process of a first vertebra and an inferior articularprocess of an adjacent vertebra. The spacer can be implanted anddeployed to help stabilize adjacent vertebrae with adhesives and/or todeliver a medication. For example, in some embodiments, the spacer canbe at least temporarily maintained in a desired position via an adhesivewhile the band 240 is positioned relative to the first vertebra and/orsecond vertebra. In some embodiments, an adhesive can be used inconjunction with the band 240 to stabilize and/or fixate the firstvertebra to the second vertebra.

In some embodiments, the spacer can be, for example, substantially discshaped. In other embodiments, the spacer can be other shapes, e.g.,square, elliptical, or any other shape. The spacer can include a firstside and a second side. The first side and/or the second side can be,for example, convex, concave, or flat. Said another way, the first sideof the spacer can be concave, convex, or flat, and the second side ofthe spacer can be concave, convex, or flat, for example, the first sidecan be concave and the second side concave, the first side can beconcave and the second side convex, etc. The spacer can include the samematerials as band 140. In some embodiments, the spacer can includesubstances configured to release medication and/or increase thestability of a vertebra and/or band 140. As discussed above, thesubstances can include a medicine(s) and/or an adhesive(s).

FIGS. 9A-10B illustrate a flexible elongate body 340 (also referred toherein as “band”), an anchor 380, and a spacer 354 collectively used tostabilize adjacent vertebrae according to an embodiment. As shown inFIG. 9A, the band 340 can be used to stabilize a first vertebra 4A and asecond vertebra 4B via the spinous articular process 16A (also referredto herein as “process 16A”) of the first vertebra 4A and the spinousarticular process 16B (also referred to herein as “process 16B”) of thesecond vertebra 4B. The band 340 can be similar to band 140 describedabove with reference to FIG. 7 and can include similar components. Byway of example, band 340 includes a fastener mechanism 350 (FIG. 9B), abody portion 345 (FIG. 9B), and a distal end portion 348 (FIG. 10B). Asshown in FIGS. 9A-10B, the band 340 can be monolithically constructed inan elongate shape and can have a substantially rectangularcross-sectional shape. More specifically, the band 340 can have asubstantially rectangular shape including rounded edges configured toreduce digging or grinding into the bone or portion thereof.

The fastener mechanism 350 defines a lumen 366 and includes a ratchet362. The lumen 366 of the fastener mechanism 350 receives the distal endportion 348 of the band 340 such that the body portion 345 forms a loopthat substantially encircles the process 16A of the first vertebra 4Aand the process 16B of the second vertebra 4B. While not shown in FIGS.9A-10B, the band 340 includes a gear rack that can be similar to or thesame as the gear racks described above in the previous embodiments. Inthis manner, the ratchet 362 is configured to engage the gear rack ofthe band 340 to maintain the distal end portion 348 of the band 340within the lumen 366 (as described in detail above).

The anchor 380 is configured to substantially surround a portion of theband 340 as shown in FIGS. 9A and 9B. More specifically, the anchor 380can be a hook (e.g., a J-hook or the like) configured to substantiallysurround the band 340 on at least three sides (e.g., all of the sides ofthe band 340 except the side disposed adjacent the first vertebra 4A).The anchor 380 defines an aperture (not shown in FIGS. 9A-10B)configured to receive a fastener 385. In this manner, the fastener 385can be advanced into the process 16A of the first vertebra 4A to affixthe anchor 380 thereto. Moreover, with the anchor 380 disposed about theportion of the band 340, the anchor 380 can limit the movement of theband 340 relative to the first vertebra 4A and the second vertebra 4B(e.g., in the posterior or anterior direction).

The spacer 354 is disposed between the process 16A of the first vertebra4A and the process 16B of the second vertebra 4B. The spacer 354 can beany suitable shape, size, or configuration. For example, as shown inFIGS. 10A and 10B, the spacer 354 can be substantially rectangular andcan include a first indentation 351, configured to receive a portion ofthe process 16A, and a second indentation 352, configured to receive aportion of the process 16B. Thus, the first indentation 351 is disposedopposite the second indentation 352 and a desired distance is definedtherebetween. For example, in some embodiments, the distance between thefirst indentation 351 and the second indentation 352 is associated witha desired distance between the process 16A of the first vertebra and theprocess 16B of the second vertebra 4B. Expanding further, when the band340 is tightened (e.g., the distal end portion 348 is advanced throughthe fastener mechanism 350), the spacer 354 can be configured to limitthe tightening of the band 340 such that the desired distance betweenthe process 16A and the process 16B is retained. In this manner, thespacer 354 can substantially limit undue pressure on the disc 6 (FIGS.9A and 10A), an artificial disk, or a cage disposed between the firstvertebra 4A and the second vertebra 4B, otherwise induced by overtightening the band 340.

As shown in FIG. 10B, the spacer 354 further includes a first side wall356 and a second side wall 358. The first side wall 356 and the secondside wall 358 can be configured to each define a channel 359 (shown onthe first side wall 356 in FIGS. 9A and 9B). The channel 359 can receivea portion of the band 340 such that the walls defining the channel 359substantially limit a posterior and/or an anterior movement of theportion of the band 340 (e.g., the walls form a barrier that limit themovement of the band 340 relative to the spacer 354). In this manner,the spacer 354 can reduce slippage of the band 340 relative to theprocess 16A and/or process 16B that may otherwise occur duringtightening of the band 340. While the anchor 380 is shown as beingdisposed at a posterior position relative to the band 340, in otherembodiments, the anchor 380 can be disposed in an anterior configurationwherein the fastener 385 is disposed on an anterior portion of theprocess 16A relative to the band 340.

While the anchor 380 is shown as being independently formed from theband 340, in other embodiments, an anchor can be monolithically formedwith a band. For example, FIGS. 11A-11C illustrate a flexible elongatebody 440 (also referred to herein as “band”) according to an embodiment.The band 440 can be similar to band 140 described above with referenceto FIG. 7 and can include similar components. By way of example, band440 includes a fastener mechanism 450, a body portion 445, a distal endportion 448, and an anchor portion 480. As shown in FIGS. 11A-11C, theband 440 can be monolithically constructed in an elongate shape and canhave a substantially rectangular cross-sectional shape. Morespecifically, the band 440 can have a substantially rectangular shapeincluding rounded edges configured to reduce digging or grinding intothe bone or portion thereof. The fastener mechanism 450 defines a lumen466 and includes ratchet 462. The body portion 445 includes a gear rack447 having a set of gears 464. In this manner, the distal end portion448 can be inserted into the lumen 466 of the fastener member 450 suchthat the gear rack 447 engages the ratchet 462, as described in detailabove. The anchor portion 480 is monolithically formed with the band440. More specifically, the anchor portion 480 can be a substantiallyannular portion of the band 480 configured to define an aperture 482.The aperture 482 can receive a fastener 485 (FIGS. 12A and 12B), asfurther described herein.

As shown in FIGS. 12A and 12B, the band 440 can be used to stabilize afirst vertebra 4A and a second vertebra 4B via the spinous articularprocess 16A (also referred to herein as “process 16A”) of the firstvertebra 4A and the spinous articular process 16B (also referred toherein as “process 16B”) of the second vertebra 4B. More specifically,the lumen 466 of the fastener mechanism 450 can receive the distal endportion 448 of the band 440 such that the body portion 445 forms a loopthat substantially encircles the process 16A of the first vertebra 4Aand the process 16B of the second vertebra 4B (as described in detailabove). The fastener 485 can be inserted into the aperture 482 (FIGS.11A-11C) and advanced into the process 16A of the first vertebra 4A toaffix the anchor portion 480 thereto. In some embodiments, the fastener485 can be inserted into the aperture 482 and at least partiallyadvanced into the process 16A of the first vertebra 4A prior to thedistal end portion 448 of the band 440 being inserted into the lumen 466of the fastener mechanism 450. In some embodiments, the fastener 485 canbe advanced into the process 16A concurrently with the distal endportion 448 being advanced through the lumen 466.

With the anchor portion 480 affixed to the process 16A via the fastener485, movement of the band 440 in the anterior and/or posteriordirection, relative to the process 16A is substantially limited. Inaddition, a spacer 454 can be disposed between the process 16A of thefirst vertebra 4A and the process 16B of the second vertebra 4B prior totightening the band 440 about the process 16A of the first vertebra 4Aand the process 16B of the second vertebra 4B. For example, in someembodiments, the spacer 454 can be disposed between the process 16A ofthe first vertebra 4A and the process 16B of the second vertebra 4Bafter advancing the fastener 485 into the process 16A and prior toadvancing the distal end portion 448 of the band 440 through the lumen466. In other embodiments, the spacer 454 can be disposed between theprocess 16A of the first vertebra 4A and the process 16B of the secondvertebra 4B prior to the insertion of the fastener 454 in the process16A and prior to the insertion of the distal end portion 448 into thelumen 466. In still other embodiments, the spacer 454 can be disposedbetween the process 16A of the first vertebra 4A and the process 16B ofthe second vertebra 4B after the fastener 485 is advanced into theprocess 16A and after the band 440 is partially tightened. The spacer454 can be similar to the spacer 354 described above with reference toFIGS. 9A-10B. Therefore, the form of spacer 454 is not described indetail herein. As described above, the spacer 454 can reduce slippage ofthe band 440 relative to the process 16A and/or process 16B that mayoccur during tightening of the band 440.

While the anchor portion 480 is shown in FIGS. 11A-12B as beingsubstantially aligned with the body portion 445 of the band 440 (e.g., acenter point of the annular shaped anchor portion 480 is positioned on alongitudinal axis or centerline of the band 440), in some embodiments, aflexible elongate body can include an anchor portion that is notpositioned on a longitudinal axis or centerline. For example, FIGS.13A-13C illustrate a flexible elongate body 540 (also referred to hereinas “band”) according to an embodiment. The band 540 can be similar toband 140 described above with reference to FIG. 7 and can includesimilar components. By way of example, band 540 includes a fastenermechanism 550, a body portion 545, a distal end portion 548, and ananchor portion 580. As shown in FIGS. 13A-13C, the band 540 can bemonolithically constructed in an elongate shape and can have asubstantially rectangular cross-sectional shape. More specifically, theband 540 can have a substantially rectangular shape including roundededges configured to reduce digging or grinding into the bone or portionthereof. The fastener mechanism 550 defines a lumen 566 and includesratchet 562. The body portion 545 includes a gear rack 547 having of aset of gears 564. In this manner, the distal end portion 548 can beinserted into the lumen 566 of the fastener member 550 such that thegear rack 547 engages the ratchet 562, as described in detail above.

The anchor portion 580 is monolithically formed with the band 540. Morespecifically, the anchor portion 580 can be a lateral protrusionextending from a side of the band 540. For example, in some embodiments,the anchor portion 580 can extend substantially perpendicularly from aside of the band 540. In other embodiments, the anchor portion 580 canextend from the side of the band 540 at any suitable angular orientation(i.e., an angular orientation other than the perpendicular orientation(e.g., other than 90 degrees)). The anchor portion 580 can besubstantially annular such that the anchor portion 580 defines anaperture 582. The aperture 582 can receive a fastener 585 (FIGS. 14A and14B), as further described herein.

As shown in FIGS. 14A and 14B, the band 540 can be used to stabilize afirst vertebra 4A and a second vertebra 4B via the spinous articularprocess 16A (also referred to herein as “process 16A”) of the firstvertebra 4A and the spinous articular process 16B (also referred toherein as “process 16B”) of the second vertebra 4B. More specifically,the lumen 566 of the fastener mechanism 550 can receive the distal endportion 548 of the band 540 such that the body portion 545 forms a loopthat substantially encircles the process 16A of the first vertebra 4Aand the process 16B of the second vertebra 4B (as described in detailabove). The fastener 585 can be inserted into the aperture 582 (FIGS.13A-13C) and advanced into the process 16A of the first vertebra 4A toaffix the anchor portion 580 thereto.

With the anchor portion 580 affixed to the process 16A via the fastener585, movement of the band 540 in the anterior and/or posteriordirection, relative to the process 16A is substantially limited. Inaddition, a spacer 554 can be disposed between the process 16A of thefirst vertebra 4A and the process 16B of the second vertebra 4B. Thespacer 554 can be similar to the spacer 554 described above withreference to FIGS. 9A-10B. Therefore, the form of spacer 554 is notdescribed in detail herein. As described above, the spacer 554 canreduce slippage of the band 540 relative to the process 16A and/orprocess 16B that may occur during tightening of the band 540.

While the anchor portion 580 is shown extending from a particular sideof the band 540 in FIGS. 13A-14B, in other embodiments, an anchorportion can extend from either side of a band. Moreover, while the band540 is shown in FIGS. 13A-14B as including a single anchor portion 580,in other embodiments, a band can include a first anchor portionextending from a first side of the band and a second anchor portionextending from a second side, opposite the first side, of the band. Insuch embodiments, the first anchor portion and the second anchor portioncan be aligned along a length of a band or the first anchor portion andthe second anchor portion can be offset along the length of the band.

FIG. 15 illustrates a flexible elongate body 640 (also referred toherein as “band”), and a spacer 654 collectively used to stabilizeadjacent vertebrae according to an embodiment. While not shown in FIG.15, flexible elongate body can be used with an anchor, such as, forexample, an anchor 280, anchor 380 and/or anchor 480, as shown anddescribed above. As shown in FIG. 15, the band 640 can be used tostabilize a first vertebra 4A and a second vertebra 4B via the spinousarticular process 16A (also referred to herein as “process 16A”) of thefirst vertebra 4A and the spinous articular process 16B (also referredto herein as “process 16B”) of the second vertebra 4B. The band 640 canbe similar to band 140 described above with reference to FIG. 7 and caninclude similar components. By way of example, band 640 includes afastener mechanism 650, a body portion 645, and a distal end portion(not shown). Unlike FIGS. 9A-10B, which depict a spacer havingindentations and channels, spacer 654 can be substantially cylindricalin shape, and can include a first lumen 659 to receive a portion of band640, and a second lumen 659 to receive a second portion of band 640.Similar to the spacer 354, the spacer 654 is disposed between theprocess 16A of the first vertebra 4A and the process 16B of the secondvertebra 4B. The spacer 654 can be any suitable shape, size, orconfiguration. In some embodiments, the diameter of the spacer 654 canbe associated with a desired distance between the process 16A of thefirst vertebra and the process 16B of the second vertebra 4B. Similar tospacer 354, when the band 640 is tightened, the spacer 654 can beconfigured to limit the tightening of the band 640 such that the desireddistance between the process 16A and the process 16B is retained.

Referring now to FIG. 16, a flowchart illustrates a method 790 forstabilizing a first bone portion and a second bone portion. The method790 includes disposing a flexible band into contact with a first boneportion and into contact with a second bone portion, at 792. In someembodiments, the flexible band can be, for example, a flexible elongatebody such as the flexible elongate body 340 described above withreference to FIGS. 9A-10B. The flexible band can define an apertureconfigured to receive a fastener that can secure the flexible band tothe first bone. The fastener can be any suitable fastener such as, forexample, a mechanical fastener (e.g., a pin, a nail, a screw, a bolt, astaple, or the like), a chemical fastener (e.g., an adhesive, tape, orthe like), or any other suitable fastener or combination thereof.

The method 790 includes advancing a portion of the flexible band throughan attachment connection until the first bone portion and the secondbone portion are stabilized, at 794. The attachment portion can besubstantially similar to the attachment portion (e.g., the fastenermechanism) 340 described herein. The advancing of the portion of theband through the attachment connection can be such that, for example,the band tightens about the first bone portion and about the second boneportion to move the first bone portion from a first orientation relativeto the second bone portion to a second orientation relative to thesecond bone portion. Moreover, the second orientation of the first boneportion relative to the second bone portion can correspond to astabilized orientation of the first bone portion and the second boneportion. In some embodiments, the first bone portion and the second boneportion can be a portion of a first vertebra and a portion of a secondvertebra, respectively. For example, in some embodiments, the first boneportion and the second bone portion can be a spinous articular processof a first vertebra and a spinous articular process of a secondvertebra, respectively. In other embodiments, the first bone portion andthe second bone portion can be a transverse articular process of a firstvertebra and a transverse articular process of a second vertebra,respectively.

In some embodiments, a spacer can be optionally disposed between thefirst bone portion and the second bone portion to facilitate thestabilization. For example, in some embodiments, the spacer can define achannel configured to receive a portion of the flexible band, therebylimiting or reducing slippage of the flexible band relative to the firstbone portion and/or the second bone portion. In some embodiments, aspacer can define a desired distance between the first bone portion andthe second bone portion.

The method further includes advancing a portion of the fastener throughan aperture and into the first bone portion until the flexible band issecured to the first bone portion, at 796. In some embodiments, thefastener can be advanced through a pre-drilled hole in the first boneportion. In other embodiments, the fastener can be a self-tapingfastener such as, for example, a self-taping screw. In this manner, thefastener can substantially limit slippage of the flexible band relativeto the first bone portion and or the second bone portion.

Any of the embodiments, described above can be packaged independently orin any suitable combination. For example, in some embodiments, a kit caninclude at least flexible elongate body (e.g., a band) and a fastener.The band can include an interface portion configured to receive thefastener. For example, the band can be similar to or the same as theband 440 described above with reference to FIGS. 11A-12B. In thismanner, the flexible band is configured to stabilize a first boneportion and a second bone portion. The fastener is configured to anchorthe flexible band to the first bone portion such that the first boneportion, the second bone portion, and the flexible band are stabilizedafter being anchored. In some embodiments, the kit can include multiplefasteners of differing kinds. For example, in some embodiments, the kitcan include a first fastener that is a bolt and include a secondfastener that is a staple. In this manner, the kit can include multiplefasteners configured for use with varying bone structures. By way ofexample, in some embodiments, the relatively small size of a staple canbe suitable for use on a cervical vertebra while the relatively largesize of a bolt can be suitable for use on a lumbar vertebra.

In some embodiments, the kit can include a spacer and/or implant. Forexample, in some embodiments, the kit can include a spacer that issimilar to or the same as the spacer 354 described above with referenceto FIGS. 9A-10B. In some embodiments, the kit can include a set ofspacers where each spacer has a size different than the other spacersincluded in the set. For example, in some embodiments, the kit caninclude (1) a first spacer, having a first size and that is configuredto be disposed between a spinous articular process of a first cervicalvertebra and a spinous articular process of a second cervical vertebra,and (2) a second spacer having a second size greater than the first sizeand that is configured to be disposed between a spinous articularprocess of a first lumbar vertebra and a spinous articular process of asecond lumbar vertebra. In this manner, the appropriately sized spacercan be selected to stabilize a first and second vertebra.

While various embodiments have been described above, it should beunderstood that they have been presented by way of example only, notlimitation, and various changes in form and details may be made. Forexample, while the embodiments are illustrated here as being disposedabout a spinous articular process of a first vertebra and a spinousarticular process of a second vertebra, in other embodiments, a flexibleelongate body (e.g., a band) can be disposed about another portion ofone or more vertebra. For example, in some embodiments, a flexibleelongate body can be dispose about a transverse articular process of afirst vertebra and a transverse articular process of a second vertebra.In such embodiments, the band can be tightened about the vertebrae tooffset or correct misalignment of a portion of the spine (e.g.,scoliosis, or the like).

While the descriptions given are with reference to stabilizing vertebra,another bone(s) such as for example, a sternum and/or a rib(s) could bestabilized using the flexible fastening bands described herein. Inanother example, a flexible fastening band can be used to stabilizeand/or fixate an intramedullary (IM) rod or nail. For example, theflexible fastening band can be used at different longitudinal locationsalong an IM rod or nail, and used to couple adjacent bone portions tothe IM rod or nail. In such situations, a given flexible fastening bandcan fix a first bone portion, the IM rod or nail, and a second boneportion, all of which are positioned between the distal portion and theattachment connection of the flexible fastening band. In yet anotherexample, a flexible fastening band can be used to stabilize and/orfixate a bone fragment. While various embodiments have been describedabove with regard to natural bone spaces, (e.g., the space between aninferior articulate process and a superior articulate process), in otherembodiments, the bone spacing can be man-made (e.g., sternum splitduring a heart procedure), and/or due to an injury (e.g., broken bone).

Where methods described above indicate certain events occurring incertain order, the ordering of certain events can be modified.Additionally, certain of the events can be performed concurrently in aparallel process when possible, as well as performed sequentially asdescribed above. For example, while the method 790 described aboveincludes advancing a portion of the band into the attachment connectionprior to advancing the fastener, in some embodiments, the fastener canbe at least partially advanced into a bone portion prior to the portionof the band being advanced through the attachment portion. In someembodiments, at least a portion of the advancing of the fastener intothe bone portion and at least a portion of the advancing of the portionof the band into the attachment connection can be done concurrently(e.g., simultaneously or alternatively in relatively small increments).

By way of another example, in some embodiments, a spacer (e.g., thespacer 454 described above with reference to FIGS. 12A and 12B) can bedisposed between a first bone portion and a second bone portion prior totightening a band (e.g., the band 440 described above) about the firstbone portion and the second bone portion. For example, in someembodiments, the spacer can be disposed between the first bone portionand the second bone portion after advancing a fastener (e.g., thefastener 485 described above) into the bone portion and prior toinserting a distal end portion of the band into an attachmentconnection. In other embodiments, the spacer can be disposed between thefirst bone portion and the second bone portion prior to the insertion ofthe fastener in the first bone portion and prior to the insertion of thedistal end portion into the attachment connection. In still otherembodiments, the spacer can be disposed between the first bone portionand the second bone portion after the fastener is completely advancedinto the first bone portion and after the band is partially tightenedabout the first bone portion and the second bone portion.

Any portion of the apparatus and/or methods described herein may becombined in any combination, except mutually exclusive combinations. Theembodiments described herein can include various combinations and/orsub-combinations of the functions, components and/or features of thedifferent embodiments described.

1-21. (canceled)
 22. A method, comprising: disposing a flexible bandinto contact with a first bone portion and into contact with a secondbone portion, wherein the flexible band comprises an aperture configuredto receive a fastener, wherein the flexible band comprises an attachmentconnection, wherein the flexible band comprises an elongate body;advancing a portion of the elongate body through the attachmentconnection of the flexible band to form a loop, wherein the flexibleband comprises a ratchet configured to allow the portion to travelthrough the attachment connection in a first direction and substantiallylimit the movement of the portion in a second direction, opposite thefirst direction; and advancing a portion of the fastener through theaperture and into the first bone portion.
 23. The method of claim 22,wherein the attachment connection is monolithically formed with theelongate body.
 24. The method of claim 22, wherein an anchor comprisesthe aperture, wherein the anchor is monolithically formed with theelongate body.
 25. The method of claim 22, wherein an anchor comprisesthe aperture, further comprising disposing the anchor about the elongatebody.
 26. The method of claim 22, further comprising disposing animplant between the first bone portion and the second bone portion. 27.The method of claim 22, further comprising advancing the portion of theelongate body through the attachment connection until the first boneportion and the second bone portion are stabilized.
 28. The method ofclaim 22, wherein the elongate body comprises a centerline between aproximal end of the elongate body and a distal end of the elongate body,wherein the aperture is substantially centered along the centerline. 29.The method of claim 22, wherein the elongate body comprises a centerlinebetween a proximal end of the elongate body and a distal end of theelongate body, wherein the aperture is laterally offset from thecenterline.
 30. The method of claim 22, wherein the first bone portionis a spinous process of a first vertebra and the second bone portion isa spinous process of a second vertebra.
 31. The method of claim 22,wherein the first bone portion is a first transverse process of a firstvertebra and the second bone portion is a second transverse process of asecond vertebra.
 32. The method of claim 22, further comprisingadvancing the portion of the elongate body through the attachmentconnection of the flexible band such that the first bone portion ismoved from a first orientation relative to the second bone portion to asecond orientation relative to the second bone portion.
 33. A method,comprising: positioning a flexible band relative to a first bone portionand a second bone portion, wherein the flexible band comprises a distalend portion, a body portion located proximal to the distal end portion,an anchor portion comprising an aperture, and an attachment connectionlocated proximal to the body portion; advancing the distal end portionof the flexible band through the attachment connection of the flexibleband, wherein the flexible band forms a loop, wherein the flexible bandcomprises a ratchet configured to allow the flexible band to travelthrough the attachment connection in a first direction and substantiallylimit the movement of the flexible band in a second direction, oppositethe first direction; and advancing a fastener through the aperture andinto the first bone portion.
 34. The method of claim 33, wherein theflexible band comprises a longitudinal axis, wherein the aperture islocated along the longitudinal axis.
 35. The method of claim 33, whereinthe flexible band comprises a longitudinal axis, wherein the aperture isoffset from the longitudinal axis.
 36. The method of claim 33, whereinthe anchor portion is movable along the body portion.
 37. The method ofclaim 33, wherein the anchor portion is fixed relative to the bodyportion.
 38. A method, comprising: disposing a flexible band intocontact with a first bone portion and into contact with a second boneportion, wherein the flexible band comprises an anchor portion, whereinthe flexible band comprises an attachment connection; advancing aportion of the flexible band through the attachment connection to form aloop, wherein the flexible band comprises a ratchet configured to allowthe portion to travel through the attachment connection in a firstdirection and substantially limit the movement of the portion in asecond direction, opposite the first direction; and advancing a portionof a fastener through an aperture of the anchor portion and into thefirst bone portion.
 39. The method of claim 38, wherein the attachmentconnection is monolithically formed with the flexible band.
 40. Themethod of claim 38, wherein the anchor portion is monolithically formedwith the flexible band.
 41. The method of claim 38, wherein the anchorportion is movable along the flexible band.